Ventilators are using up all the creative oxygen
The anxiety over the number of ventilators is a waste. Mostly, it is generating fear and, more tragically, it is misdirecting priorities. The energy and brainpower can be better used. No matter how patriotic, well-intended or coerced, no company can manufacture care capacity.
Dr. Fauci did us an excellent service by giving us the phrase “flatten the curve.” Explicitly, he wanted us to prevent the healthcare system from getting “overwhelmed.” Yet, ventilators don’t get overwhelmed. Beds don’t either. What gets overwhelmed? People. We need to flatten the curve because there is a finite capacity to provide critical care. Ventilators aren’t enough.
Critical care capacity is a complex system
The intensive care unit is a serious place. The last resort for respiratory distress is mechanical ventilation. Machines can breathe for you only temporarily because the risk of further complications climbs by the day — complications that are as serious as the conditions that landed you on a ventilator in the first place.
Ventilation is more involved than most can imagine. Breathing is instinctual, and we naturally fight a machine trying to do it. (imagine trying to exhale while the device is pushing air into your lungs). Doctors start by paralyzing you with drugs so they do not have to fight your reflexes. They place tubes for air and food leaving you sedated days. Your vocal cords are now useless and you are mostly asleep. Unable to move, talk or stay awake connected to a machine that cannot stop working even for a minute.
Attentive monitoring is mandatory. A team of highly skilled professionals is needed now: more than one MD, pharmacists, respiratory therapists, critical care nursing team, among others. To save your life, you must be attentively monitored because you are sick enough to be in the ICU, and the risk of serious complications is climbing by the day.
Human dexterity and cognitive load is a real factor. Humans cannot work like ventilators. Performance can deteriorate over time, especially when dealing with such a constant load. How many hours per day do you want your nurse to work?
Everyone is multi-tasking. Everyone on the care team typically has many patients. That means by definition they are dynamically prioritizing tasks, and they are constantly interrupted. It is easy to see this at the bedside: doctors rounding, techs doing treatments, locating missing meds/supplies, questions from the family, calls from the emergency department or surgery et al. Busy with bursts of panic, followed by heroism.
There is a worrisome drug shortage. Long before we heard of COVID-19, hospital pharmacists and the physicians have been struggling with alternatives when the preferred drugs are not available. These alternatives are, by definition, less than ideal. The alternative options can be contraindicated, they can extend the stay and add risk for the patient. Depending on the situation, changes to the hospital formulary and supply chain need to happen. (read: not timely or easily made available). They don’t teach just-in-time inventory systems in medical school.
“Where will we get the 90,000 nurses to staff the 40,000 patients on new ventilators?”
— March 23 Director, Critical Care
They started overwhelmed
Despite decades of focus and unimaginable sums invested in technology, training, and projects, it remains overwhelmed. On October 23, 2019, National Academy of Medicine, released a 312-page report highlighting what today’s healthcare system is doing to our clinicians.
Between one-third and one-half of U.S. clinicians experience burnout and addressing the epidemic requires systemic changes by health care organizations, educational institutions, and all levels of government, says a new report from the National Academy of Medicine.
Burnout — characterized by emotional exhaustion, detachment, and a low sense of personal accomplishment — can jeopardize patient care and cause doctors, nurses, and other clinicians to leave the health care profession altogether. It is specifically job-related and not an individual mental health diagnosis, says the report. Mounting pressures in the health care system have contributed to burnout — including long hours, technologies and documentation requirements that detract from patient care, difficulties with work-home balance, and insufficient job resources, such as unsupportive organizational culture and ineffective team structures.
Personal stress management strategies are not sufficient to address the issue of clinician burnout, says the report. It is critical to address burnout not as an individual issue, but rather as a systems issue that emanates from workplace culture, health care policies and regulations, and societal expectations.
If they were exhausted just five months ago, how do you think they are feeling now?
Time to change the discussion
It’s up to the people to ramp up the care capacity. We don’t need a 10% improvement. We need a 10X improvement. I believe strongly that this can only happen when people mobilize organically. We cannot wait for the government to lead it. We can do it. A mobilized population can turn the most cynical and bureaucratic.
- Manage Care Capacity Regionally. If it is not there yet, a big white Navy hospital boat is not coming dock near you! Hospital capacity is a regional issue. It is surprising to most how much the physicians and administrators can influence where sick people go for care and how long they stay. We need to pivot quickly from “how to test” to “where to go,” this will require creativity and imagination. Community leadership can collaborate on logistics in managing hospital demand. Some facilities might be better equipped to handle more oncology patients and free up resources for others to take on more respiratory cases. Its time to get creative.
- Protect the time we have. Minutes count now more than ever. But what isn’t so obvious is that hierarchy matters less. Everyone can play a role in protecting our care capacity. It is what matters, not the letters after your name or your status as a patient’s family member. These minutes need to be hoarded like its toilet paper. Great judgment should be exercised before one demands time from our care capacity. Doctors should be careful using nursing time; nurses should be cautious using housekeeping time, etc. Collectively we can help these people outside the hospital. What can you do: shopping, meal prep, deliveries, errands? It takes time to live under social distancing. Anywhere we can add a few minutes to their day, if even to reduce their cognitive load, it is helpful. Complex systems have feedback loops and consequences akin to the “butterfly effect.” Lost care capacity is lost forever. Its time to get creative.
- Scale-out by skilling up. Hand in hand to protecting time — add to the available capacity by getting licensed. The education requirements of most clinical positions can be, at least, partially completed online. Get started today. The long term capacity requirements are only going up. Our lack of capacity is costing the USA trillions, here is a rewarding job with excellent long term job security anywhere in the world.
These unprecedented times are also an opportunity to do unexpected things. Even the most optimistic forecast of when things will get back to normal is months and months away. I believe the government offers only marginal improvement. Faster than a vaccine, we could have an entire army of people ready to provide care capacity. No one knows what can happen when millions of people mix creative thinking with logistics and take action. It can hasten our time in seclusion and buttress our future with unexpected innovation.
Klompas, Michael, Richard Branson, Eric C. Eichenwald, Linda R. Greene, Michael D. Howell, Grace Lee, Shelley S. Magill, Lisa L. Maragakis, Gregory P. Priebe, Kathleen Speck, Deborah S. Yokoe, and Sean M. Berenholtz. “Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals: 2014 Update.” Infection Control and Hospital Epidemiology 35, no. 8 (2014): 915–36. Accessed April 1, 2020. doi:10.1086/677144.